中風後門診物理治療是否達到心肺功能訓練目標－某醫學中心之現況

The Effect of Outpatient Physiotherapy after Stroke on Cardiopulmonary Training Goals: The Current Situation in a Single Medical Center

盧怡君(Yi‐Chun Lu) ； 黃佳琦(Chia‐Chi Huang) ； 周正亮(Chen‐Liang Chou)

《台灣復健醫學雜誌》 43卷2期 (2015/06) Pp. 91-97

https://doi.org/10.6315/2015.43(2)03

摘要

研究背景及目的：中風後心肺功能的下降逐漸引起重視，中風後病人的各項心血管功能，以及肌肉纖維組成的改變而造成體適能下降，也有研究指出中風後的病人最高攝氧量（peak oxygen consumption）下降。進而造成可執行的日常生活功能減少，而進入失能與活動能力下降的惡性循環。而不論是早期或晚期的中風後心肺復健都顯示可改善病人心肺功能，尤其是發病前生活型態即較少運動的族群，改善更明顯。然傳統復健規畫多數著重在患側肢體肌力及能力之恢復，較不重視是否達成其心肺復健所要求之目標。以具行走能力患者而言，下肢大塊肌肉的有氧訓練如：行走、跑步機、腳踏車及爬階梯訓練等常為主要心肺復健模式用來達到中強度心肺復健的目標。而本研究的目的為評估中風病人於門診接受神經復健過程中是否也能達到中強度心肺復健的指標。研究方法：本研究以病歷回顧的方法，收集台北榮總2014年7月到12月間因中風造成偏癱接受門診復健並符合收案條件的病人，共38位，其中依據排除標準排除後，共34人。資料收集包括了病患基本資料、中風週數、運動過程心跳數、接受下肢復健類型和復健時間。研究結果：整體平均運動強度為儲備心跳率（heart rate reserve）25%，並無法達成美國運動醫學學會（American College of Sports Medicine）指導手冊所建議之中風族群儲備心跳率40%持續20分鐘以上或多次10分鐘之心肺訓練目標，而運動過程中達儲備心跳率40%的患者也無法維持該強度至10分鐘。跑步機訓練最高強度平均為儲備心跳率32%，腳踏車訓練最高強度平均為儲備心跳率18%。結論：回顧目前文獻，中風後神經復健過程中，使用儲備心跳率作為評估心肺復健指標之文獻，多數為儲備心跳率達23~25%，並無法達成美國運動醫學學會之要求目標。本院統計數字為達儲備心跳率25%，符合其他文獻敘述，無法達到儲備心跳率40%維持大於20分鐘或多次10分鐘的預定心肺強度。故後續中風病人之物理復健可視病人狀況，逐步調整其運動強度，使病人於訓練肌力、平衡以及日常生活技巧外，亦能達成心肺復健目標，減少再次中風之危險因子，並改善病人的體適能，增加日常生活能力。

關鍵字

門診物理治療 ； 中風 ； 心肺功能 ； 儲備心跳率

並列摘要

Study background and objectives: Reduced cardiopulmonary function after stroke has drawn increasing attention. Cardiovascular function and muscle fiber composition change after stroke, leading to a decline in physical fitness. Some studies have also reported decreased maximum oxygen uptake after stroke, which would further reduce patient ability to perform daily life functions, inducing a circle of disability and reduced mobility. Cardiopulmonary rehabilitation after early or late strokes has been found to improve cardiopulmonary function; these improvements are especially noticeable in patients with lower levels of physical activity before their stroke onset. However, traditional rehabilitation programs mostly focus on recovery of limb muscle power and ability on the affected side, while the goal of cardiopulmonary rehabilitation is less prioritized. For patients able to walk, aerobic training of the large muscle groups of the lower limbs, such as walking, treadmill, cycling, stair climbing, etc., is the main method used for moderate-intensity cardiopulmonary rehabilitation. This study evaluated whether stroke patients could achieve moderate-intensity cardiopulmonary rehabilitation during the course of outpatient neurorehabilitation. Study method: By applying the case review method, data were collected from a total of 38 patients who received outpatient rehabilitation at Taipei Veterans General Hospital between July and December of 2014 due to hemiplegia caused by stroke and also met the study inclusion criteria. After applying the exclusion criteria, a total of 34 cases were analyzed. Patient data included general information, heart rate during exercise, types of lower limb rehabilitation, and rehabilitation time. Study results: After applying the exclusion criteria, a total of 34 cases were included in the statistical analysis. Records from 129 sessions were obtained over two weeks of tracking. The average patient age was 58.7±16.1 years and 28 patients (82.4%) were male; 19 subjects (55.9%) had experienced ischemic strokes, with an average elapsed time of 36.2±26.2 months since stroke onset. Among rehabilitation regimens, 16 patients received treadmill training, one walked, none participated in stair climbing, and 17 patients underwent rehabilitation that involved cycling. The average heart rate before exercise was 81.6±14.7 beats per min, climbing to 93.6±14.1 during exercise; the average HRR (heart rate reserve) was 13%, with average maximum and median HRR of 25% and 21%, respectively. The predetermined cardiopulmonary intensity of 40% HRR for 20 min was not observed during exercise. Intergroup analysis between treadmill and cycling training showed that treadmill training achieved an average maximum HRR of 32%, compared to 18% for cycling training, a statistically significant difference (p＜0.05). Conclusion: A review of the existing literature revealed that most studies that used HRR as a cardiopulmonary rehabilitation index for neurorehabilitation after stroke achieved HRR of 23~25%, short of the goal set by the American College of Sports Medicine. The 25% HRR obtained through statistical analysis of this study is consistent with the results of other studies that also failed to achieve the predetermined cardiopulmonary intensity of a 40% HRR maintained for 20 min or over several 10-min sets. Hence, future stroke physiotherapy should include gradual adjustment of exercise intensity for cardiopulmonary rehabilitation in addition to muscle power, balance, and daily life skill training; incorporating these combined rehabilitation goals may reduce risk factors for recurrent stroke and improve physical fitness and daily living activities.

並列關鍵字

outpatient physiotherapy ； stroke ； cardiopulmonary function ； heart rate reserve

參考文獻

Billinger SA, Coughenour E, Mackay-Lyons MJ, et al. Reduced cardiorespiratory fitness after stroke: biological consequences and exercise-induced adaptations. Stroke Res Treat. 2012;2012"

Mackay-Lyons MJ, Makrides L. Exercise capacity early after stroke. Arch Phys Med Rehabil. 2002;83:1697-702."

Smith AC, Saunders DH, Mead G. Cardiorespiratory fitness after stroke: a systematic review. Int J Stroke. 2012;7:499-510."

Letombe A, Cornille C, Delahaye H, et al. Early post-stroke physical conditioning in hemiplegic patients: A preliminary study. Ann Phys Rehabil Med. 2010;53:632-42."

Palmer-McLean K, Harbst KB. Stroke and brain injury. In: Durstine JL. et al. editors. ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities.3rd ed. Champaign, IL: Human Kinetics; 2009. p. 287–97."